Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain?

Relation between endurance of deep cervical flexor muscles and physical activity level, perceived stress, sleep quality, and smartphone addiction

Objective: To determine the reference values of deep cervical flexor muscle endurance and its relationship with associated parameters.Methods: The International Physical Activity Questionnaire, Perceived Stress Scale, Pittsburgh Sleep Quality Index, and Smartphone Addiction Scale-Short Version were used in the study. The craniocervical flexion test was performed to measure the endurance.Results: Endurance (mmHg) values were determined as 24.23 ± 2.39 (women), 24.15 ± 2.65 (men), and 24.19 ± 2.51 (students). The cumulative endurance (mmHg) scores were determined as 27.50 ± 21.29 (women), 27.65 ± 25.42 (men), and 27.57 ± 23.33 (students). There was no correlation between the endurance of the muscles and age, gender, body mass index, physical activity level (except walking score), perceived stress, sleep quality (except sleep latency component), and smartphone addiction (p ˃ 0.05).Conclusion: Defining the reference values of Stage 2 and cumulative endurance would be of great value for preventing, diagnosing, and managing cervical area problems.

Electromyographic Evaluation of Specific Elastic Band Exercises Targeting Neck and Shoulder Muscle Activation

Background: Specific strength training at a high intensity is effective in reducing work related neck/shoulder pain. However, it remains to be documented as to which exercises most specifically target neck and shoulder muscles at high activation level while using simple equipment as e.g., elastic bands. We hypothezised that selected exercises would specifically target the respective muscles, as follows: (1) shrugs and reverse flyes: the upper trapezius muscle, (2) cervical extension and lateral flexion: the upper neck extensor muscle, and (3) cervical flexion and rotation: the sternocleidomastoideus muscle. Methods: Eleven healthy males (25.9 ± 1.4 years, BMI 24.3 ± 1.4) with no neck/shoulder pain (VAS = 0) performed the six exercises with elastic bands at 12RM (repetition maximum) and 20RM in a randomized order. Electromyography was bilaterally recorded from the three muscles and it was normalized to maximal voluntary activation (%MVE). Exercises that evoke more than 60%MVE were considered as high intensity activation. Results: High muscle activation level was attained during 12RM in the upper trapezius muscle during shrugs (100.3 ± 29.8%MVE) and reverse flyes (91.6 ± 32.8%MVE) and in the upper neck extensor muscle during cervical extension (67.6 ± 29.8%MVE) and shrugs (61.9 ± 16.8%MVE). In the sternocleidomastoideus muscle, the highest activity was recorded during cervical flexion (51.7 ± 16.4%MVE) but it did not exceed 60%MVE. The overall activity was ~10% higher during 12RM when compared to 20RM. Conclusion: The simple exercises shrugs and reverse flyes resulted in high intensity activation of both the upper trapezius and neck extensors, while no exercises activated sternocleidomastoideus at high intensity.

Abnormal performance of cervical stabilizer muscles in individuals with low back pain

Objectives: To compare the performance of cervical stabilizer muscles using the craniocervical flexion test (CCFT) among individuals with subacute, chronic, and asymptomatic low back pain (LBP) conditions. Methods: Individuals with subacute (N = 23) and chronic LBP (N = 23) with their age- and gender-matched controls (N = 30) participated in this study. All recruited participants were required to perform the CCFT. The activation score (AS) and the performance index (PI) were recorded by an assessor who was blinded to the group of participants. Results: Approximately, 74% of subacute LBP participants and 60-65% of chronic LBP participants obtained abnormal AS and PI. AS was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0009) than the control group. Likewise, the PI was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0036) than the control group. Participants in the subacute LBP group showed significantly greater percentages of abnormal responses on the AS (P < 0.0001) and the PI (P = 0.0001) than the control. Discussion: Abnormal performance of cervical stabilizer muscles using the CCFT was demonstrated in a high proportion of participants with LBP. The findings highlight the plausible association in muscle control between cervical and lumbar stabilizers. Level of Evidence: 2b.

Concurrent validity and reliability of telerehabilitation-based physiotherapy assessment of cervical spine in adults with non-specific neck pain

INTRODUCTION

The aim of this study was to determine the concurrent validity and reliability of telerehabilitation (TR)-based evaluation of the cervical spine among adults with non-specific neck pain (NS-NP).

METHODS

A total of 11 participants with NS-NP were recruited. Pain intensity, active range of motion (AROM), posture, deep neck flexor (DNF) endurance, combined neck movements and disability were measured using face-to-face and TR methods, with a one-hour break in between. TelePTsys, an image-based TR system, was used for TR assessment.

RESULTS

A high degree of concurrent validity for pain (bias = 0.90), posture (bias = 0.96°), endurance (bias = -2.3 seconds), disability (bias = 0.10), AROM (extension bias = -0.60 cm, flexion bias = 1.2 cm, side flexion bias = -1.00, rotation bias = -0.30 cm) was found. Standard error of measurement and coefficient of variation (CV) values were within the acceptable level for concurrent validity, except the CV for cervical flexion and endurance. There was a high degree of reliability demonstrated for pain, posture, AROM, endurance and disability measurements. The average-measure interclass correlation coefficient (ICC_(3,1)) ranged from 0.96 to 0.99 for inter-rater, and 0.93 to 0.99 for intra-rater reliabilities. There was moderate agreement for combination movement for validity (78.5%, p < 0.05), inter- (78.5%, p < 0.05) and intra-rater (76.4%, p < 0.05) reliabilities.

DISCUSSION

TR-based physiotherapy assessment of cervical spine is a valid and reliable tool for measuring pain intensity, AROM, DNF muscle endurance, sagittal neck posture and disability among adults with NS-NP via telePTsys.

Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

AIMS

Neck pain is common in migraine and tension type headache (TTH). This review aimed to examine the evidence for cervical musculoskeletal impairments in these headaches.

METHODS

Databases PubMed (Medline), EMBASE, CINAHL, SCOPUS, and Web of Science were searched from inception to December 2018. Observational studies using a comparator group were included. Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies. Results were pooled using random effects meta-analysis. Level of evidence for each outcome was assigned based on risk of bias, consistency of results and magnitude of difference between participants with headache and controls. (PROSPERO registration: CRD42018083683).

RESULTS

Of 48 studies included, the majority were rated moderate risk of bias due to possible confounding influences. In total, 17 cervical outcomes were assessed, with confidence in findings ranging from very low to moderate levels. Compared to controls, participants with TTH had greater forward head posture (FHP) (MD = -6.18°, 95% CI [-8.18°, -4.18°]) and less cervical range of motion (ROM) (greatest difference transverse plane MD = -15.0°, 95% CI [-27.7°, -2.3°]. Participants with migraine demonstrated minimally reduced cervical ROM (greatest difference sagittal plane MD = -5.4°, 95% CI [-9.9°, -0.9°]. No differences presented in head posture, strength, craniocervical flexion test performance or joint position error between migraineurs and controls.

CONCLUSIONS

TTH presented with more findings of cervical musculoskeletal impairments than migraine however levels of confidence in findings were low. Future studies should differentiate episodic from chronic headache, identify coexisting musculoskeletal cervical disorders, and describe neck pain behaviour in headache.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BACKGROUND

Concussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important.

OBJECTIVES

To determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery.

DESIGN

Longitudinal observational study.

METHODS

Pre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments.

RESULTS

There was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation.

CONCLUSIONS

While no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.

Effects of dry needling in the sternocleidomastoid muscle on cervical motor control in patients with neck pain: a randomised clinical trial

Objective:

To determine the changes produced by trigger point dry needling (TrP-DN) of sternocleidomastoid in patients with neck pain, and to observe how it might modify cervical motor control (CMC).

Design:

Single-centre, randomised, double-blinded clinical trial.

Setting:

Participants were recruited through advertising. The duration of the study was 6 months.

Subjects:

Thirty-four subjects with non-specific neck pain, aged over 18 years with an active myofascial trigger point in sternocleidomastoid, participated in the study. They were randomly assigned to treatment or control groups.

Methods:

TrP-DN inside or (1.5 cm) outside of the active myofascial trigger point of sternocleidomastoid.

Main outcome measures:

CMC, visual analogue scale and cervical range of motion were assessed before treatment, immediately post treatment, and 24 h, 1 week and 1 month after the intervention; the neck disability index was evaluated before treatment and 1 month later.

Results:

With a confidence interval of 99%, TrP-DN of sternocleidomastoid was associated with a decrease in pain after 1 week and CMC improved 1 month after the intervention (p < 0.001), when compared with baseline measurements, within the experimental group; there were no statistically significant differences between experimental and control groups.

Conclusion:

The effects of TrP-DN inside and outside of active myofascial trigger points did not differ in this study. Both interventions were associated with a similar temporal effect, specifically a reduction in neck pain at 1 week and an increase CMC at 1 month. However, these findings should be interpreted with caution due to the lack of a contemporaneous untreated control group.

Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review

Background

Neck pain is a major health issue with high rates of recurrence. It presents with a variety of altered sensorimotor functions. Exercise is a cornerstone of rehabilitation and many training methods are used. Exercise is evaluated in most randomized controlled trials on its pain relieving effects. No review has assessed the effect of exercise on the altered physiological functions or determined if there are differential effects of particular training methods. This review investigated the effects of deep cervical flexor (DCF) training, a training method commonly used for patients with neck pain, and compared it to other training methods or no training on outcomes of cervical neuromuscular function, muscle size, kinematics and kinetics.

Methods

Web of Science, Scopus, CINAHL, PubMed were searched from inception until January 2018. Twelve randomized controlled trials were included that compared DCF training as sole intervention to other training or no interventions in persons with neck pain. The Cochrane Risk of Bias tool was used to assess the method quality. All outcome measures were analysed descriptively and meta-analyses were performed for measures evaluated in three or more studies.

Results

DCF training was compared to cervical endurance, strength, proprioception and mobility training, muscle stretching, and no intervention control groups. Physiological outcome measures included neuromuscular co-ordination (craniocervical flexion test), functional tasks, muscle fatigability, muscle size, kinematics (joint position sense, posture and range of motion) and kinetics (strength, endurance and contraction accuracy). Strong evidence was found for effectiveness of DCF training on neuromuscular coordination, but it had no or small effects on strength and endurance at higher loads. DCF training improved head and cervical posture, while evidence was limited or contradictory for other measures.

Conclusions

DCF training can successfully address impaired neuromuscular coordination, but not cervical flexor strength and endurance at higher contraction intensities. A multimodal training regime is proposed when the aim is to specifically address various impaired physiological functions associated with neck pain.

The influence of musculoskeletal pain disorders on muscle synergies-A systematic review

Background

Musculoskeletal (MSK) pain disorders represent a group of highly prevalent and often disabling conditions. Investigating the structure of motor variability in response to pain may reveal novel motor impairment mechanisms that may lead to enhanced management of motor dysfunction associated with MSK pain disorders. This review aims to systematically synthesize the evidence on the influence of MSK pain disorders on muscle synergies.

Methods

Nine electronic databases were searched using Medical Subject Headings and keywords describing pain, electromyography and synergies. Relevant characteristics of included studies were extracted and assessed for generalizability and risk of bias. Due to the significant heterogeneity, a qualitative synthesis of the results was performed.

Results

The search resulted in a total of 1312 hits, of which seven articles were deemed eligible. There was unclear consistency that pain reduced the number of muscle synergies. There were low consistencies of evidence that the synergy vector (W weights) and activation coefficient (C weights) differed in painful compared to asymptomatic conditions. There was a high consistency that muscle synergies were dissimilar between painful and asymptomatic conditions.

Conclusions

MSK pain alters the structure of variability in muscle control, although its specific nature remains unclear. Greater consistency in muscle synergy analysis may be achieved with appropriate selection of muscles assessed and ensuring consistent achievement of motor task outcomes. Synergy analysis is a promising method to reveal novel understandings of altered motor control, which may facilitate the assessment and treatment of MSK pain disorders.

Differences in neck surface electromyography, kinematics and pain occurrence during physiological neck movements between neck pain and asymptomatic participants. A cross-sectional study

BACKGROUND

Neck pain has been associated with altered muscle activity and impaired kinematics. Patients frequently report pain during physiological neck movements. Previously, the average muscle activity during these movements has been measured. However, muscle activity is modulated by the position in the range of movement, hence the study of neck muscle activity in discrete sections of the range of movement is warranted. Evidence is conflicting regarding range of movement restriction in neck pain. No study has assessed the point in the range of movement at which pain occurs. This study aimed to investigate neck kinematics, muscle activity and pain during physiological neck movements in participants with and without neck pain.

METHODS

Neck kinematics and surface electromyography were recorded continuously and analysed in 10° increments during forward and side flexion, extension and rotation of the neck in 20 neck pain and 20 asymptomatic participants. Point of pain occurrence in the range of movement was recorded.

FINDINGS

Neck pain participants demonstrated significantly lower activity of scalene during flexion and extension, and a non-significant higher activity in sternocleidomastoids during rotation. No differences in neck kinematics were observed. 65% of neck pain participants reported pain during at least one neck movement. Pain was reported in the last ≈20-40% of the range of movement.

INTERPRETATION

Exercises used in current practice to minimise scalene activity may not be appropriate for all neck pain patients. Restricted range of movement is not a consistent feature of neck pain. Movement associated neck pain is present at the end of range of movement, which has implications for the study of neck pain and rehabilitation.

Measurement properties of the craniocervical flexion test: a systematic review protocol

INTRODUCTION

Neck pain is the leading cause of years lived with disability worldwide and it accounts for high economic and societal burden. Altered activation of the neck muscles is a common musculoskeletal impairment presented by patients with neck pain. The craniocervical flexion test with pressure biofeedback unit has been widely used in clinical practice to assess function of deep neck flexor muscles. This systematic review will assess the measurement properties of the craniocervical flexion test for assessing deep cervical flexor muscles.

METHODS AND ANALYSIS

This is a protocol for a systematic review that will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. MEDLINE (via PubMed), EMBASE, PEDro, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus and Science Direct will be systematically searched from inception. Studies of any design that have investigated and reported at least one measurement property of the craniocervical flexion test for assessing the deep cervical flexor muscles will be included. All measurement properties will be considered as outcomes. Two reviewers will independently rate the risk of bias of individual studies using the updated COnsensus-based Standards for the selection of health Measurement Instruments risk of bias checklist. A structured narrative synthesis will be used for data analysis. Quantitative findings for each measurement property will be summarised. The overall rating for a measurement property will be classified as 'positive', 'indeterminate' or 'negative'. The overall rating will be accompanied with a level of evidence.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this is a systematic review based on published studies. Findings will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42017062175.

Effectiveness of Physiotherapy interventions plus Extrinsic Feedback for neck disorders: A systematic review with meta-analysis

PURPOSE

To systematically review the effectiveness of Physiotherapy interventions combined with extrinsic feedback (EF) compared to Physiotherapy interventions alone or control for the management of neck pain and disability.

METHODS

Randomized clinical trials were searched and retrieved from six databases, from inception through August 2016. Risk of bias of included studies was assessed using the PEDro scale. When possible data were pooled and Meta-analyses were conducted. The quality and strength of evidence for each outcome was assessed using the GRADE approach.

RESULTS

Eight studies (n = 677) were included in the review. The pooled estimates suggested Physiotherapy intervention + EF was not superior to Physiotherapy intervention alone for disability (MD = -0.38; 95%CI = -0.91 to 0.18; I² = 82%), but was superior for pain (MD = -0.37; 95%CI = -0.73 to -0.01; I² = 68%). Physiotherapy intervention + EF was not superior than control for disability scores (SMD = -3.94; 95%CI = -12.06 to 4.18; I² = 92%). Physiotherapy intervention + EF intervention was more effective than control for pain scores at short-term (SMD = -1.44; 95%CI = -2.25 to-0.63; I² = 50%). Most studies did not specify nor use the ideal characteristics of EF.

CONCLUSION

There is very low quality of evidence that Physiotherapy intervention + EF is more effective than Physiotherapy intervention alone or control for short-term pain, but not for disability. Physiotherapy intervention plus EF was more effective than Physiotherapy alone for acute neck pain, but not for chronic pain or disability. There was high risk of bias within included studies. Future studies are likely to change the estimates of the effects of Physiotherapy intervention plus EF on neck rehabilitation.